A Trauma and Systems Change

TRAUMA‐INFORMED RECOVERY: MICRO AND MACRO SYSTEMS CHANGE

TRAUMA INSTITUTE OF NEW JERSEYERIC C. ARAUZ MLER

ADJUNCT FACULTY INSTRUCTORDEPARTMENT OF PSYCHIATRY

RUTGERS ROBERT WOOD JOHNSON MEDICAL [email protected] 881 4784

Consultants of T.I.N.J.Heather Forkey, MD Assistant Director of FaCES (Foster Children Evaluation Services‐Massachusetts) and an attending pediatrician at with the Child Protection Program, both at UMass Memorial Children’s Medical Center. Assistant Professor at the University of Massachusetts Medical School. Jill Williams, MD Director of Addiction Psychiatry; Professor Rutgers Robert Wood Johnson Medical School Tracey Shors, PhD Distinguished Professor in the Department of Psychology and Center for Collaborative Neuroscience at Rutgers University. MAP TrainingBrandon Alderman, PhD Assistant Professor in the Department of Exercise Science and Sport Studies at Rutgers University. His laboratory is focused on investigating the effects of exercise on neurocognitive and physiological resilience. MAP TrainingJulie Carbray, PhD FPMHNP, PMHCNS, APN Clinical Professor University of Illinois‐Chicago Medical School; Chair APNA Clinical Psychopharmacological Institute; Administrative Director Pediatric Mood Disorders Clinic Univeristy of Illinois‐Chicago College of Medicine

“..a mind will find only according to its own

distortion.”Jiddu Krishnamurti

Freedom from the Known Krishnamurti. J. 1969. Freedom From The Known. NY, NY: Harper Collins. 11.

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Secondary Traumatic StressTherapeutic Workers

Meta‐Analysis of Risk Factors for Secondary Traumatic Stress in Therapeutic Work with Trauma Victims.

Jennifer M. Hensel, Carlos Ruiz, Caitlin Finney, and Carolyn S. Dewa. All out of Toronto, Ontario, Canada.Volume 28, Number 2, April 2015 of the Journal of Traumatic Stress. Published by the International Society for Traumatic Stress Studies.

Therapeutic Workers

Vs.

Therapists

TRAUMA ASSESSMENT BY DCF OF NJDONALD SULL PHD

MIT SLOAN SCHOOL OF MANAGEMENT

(HARVARD BUSINESS REVIEW MARCH 2015)NHS HUMAN SERVICES 10K EMPLOYEES

MASSACHUSETTS LESSONS: HEATHER FORKEY MD• MIDDLE MANAGERS

• SUPERVISION• LATERAL INTEGRATION• SUPPORT ON INITIAL PUSHBACK• LACK OF TRAUMA RESOURCES• ORGANIZATIONAL TRAUMA

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“If you get the ‘What’, then you will get the ‘How’.”

Thomas Hora MDHungarian Metapsychiatrist

What do we mean by “trauma”

OPERATIONAL DEFINITION OF TRAUMA

5 YR. SAMHSA RECOVERY TO PRACTICENATIONAL GRANT

FIDELITYREPEATABILITY

INSTANT IMPLEMENTATION

APPLICATION UNDER STRESS

Neurobiology of Helplessness

TRAUMA: Any life event occurring in a relative state of helplessness‐a car accident, the sudden death of a loved one, a frightening medical procedure (…)‐can produce the same neurophysiological changes in the

brain as do combat, rape or abuse.

Robert Scaer M.D.Neurologist, Traumatologist, Medical Director of Internationally recognized Pain

Management Center at Mapleton Rehabilitation center, Community Hospital Boulder, Colorado

TRAUMA = PERSISTENT ACUTE STRESS

RESPONSE ONE CANNOT AVOID, EVADE OR CONTROL

Tool

ANTICIPATORY STRESSIS REAL STRESS

• BLOOD PRESSURE• HEART RATE• VASCULAR DAMAGE• INFLAMMATION• METABOLIC SYNDROME

ROBERT SAPOLSKY PHDSTANFORD UNIVERSITY

NEUROSCIENTIST

NEUROPHYSIOLOGICAL

NEUROENDOCRINE

FRAMING OF BRAIN DEVELOPMENT

CORTISOLESTROGEN

TESTOSTERONEGENETIC TRANSCRIPTION

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Neocortex

Limbic

Diencephalon

Brainstem

Abstract thoughtConcrete thought

Affiliation

"Attachment"

Sexual BehaviorEmotional Reactivity

"Arousal"Appetite/Satiety

Blood PressureHeart Rate

Body Temperature

Sleep

Motor Regulation

All rights reserved © 2004 Dr. Bruce Perry 20

FRACTURING OF GLOBAL IDENTITY:DESTRUCTION OF LINEAR VISCERAL AND

COGNITIVE NARRATIVES

• Chaos Narrative: No map or destination (Frank AW. The Wounded Storyteller: Body, Illness, Ethics. Chicago: University of Chicago Press, 1995, 2013.)

• Story of Atrocity/Language of Abomination (Herman J. Trauma and Recovery. New York: Basic Books, 1997.)

• “…autobiographical memory deficits and emotional deficits and made life 'senseless'.”(Kalbe E, Brand M, Thiel A, Kessler J, Markowitsch HJ. Neuropsychological and neural correlates of autobiographical deficits in a mother who killed her children. NEUROCASE. 2008;14(1):15‐28.)

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Speaking the Unspeakable

“THE ORDINARY RESPONSE TO ATROCITIES is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud:

this is the meaning of the word unspeakable.Atrocities, however, refuse to be buried.”

― Judith Lewis Herman, Trauma and Recovery

Positive Stress Toxic Stress

Normal and essential part of healthy development

Brief increases in heart rate and blood pressure

Mild elevations in hormonal levels

Example: Final exam Playoff game.

Body’s alert systems activated to a greater degree

Activation is time-limited and buffered by caring adult relationships.

Brain and organs recover Example: Death of a

grandparent, car accident.

Occurs with strong, frequent or prolonged adversity

Disrupts brain architecture and other organ systems

Increased risk of stress-related disease and cognitive impairment

Example: abuse, neglect, caregiver substance dependence or mental illness

Intense, prolonged, repeated, unaddressed;Child or family vulnerabilities, limited supports, devel. delays

Social‐Emotional buffering, Learned skills, Parent/Child Resilience, Early Detection, Effective Intervention

Neocortex

Limbic

Diencephalon

Brainstem


Affiliation

"Attachment"




Body Temperature

Sleep

Motor Regulation


Fear/Immobility Cycle (Levine, P., In An Unspoken Voice. Berkeley: North Atlantic Books,2010, 70.)

Arousal

Unsuccessful Escape

Fear/Helplessness

Immobility

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WITH WHOM ARE YOU WORKING WITH

ADVERSE CHILDHOOD EXPERIENCESSTUDY

(ACES)

ADVERSE CHILDHOOD EXPERIENCES STUDY

(ACES)

• Physical abuse by a parent • Emotional abuse by a parent • Sexual abuse by anyone • An alcohol and/or drug

abuser in the household • An incarcerated household

member

• Someone who is chronically depressed, mentally ill, institutionalized, or suicidal

• Domestic violence • Loss of a parent • Emotional neglect • Physical neglect

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Felitti, V. J., Anda, R. F., Nordenberg, D.F., Williamson, D. F., Spitz, A.M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245-258.

ACE Score and Intravenous Drug Use

N = 8,022 p<0.00 Fellittii, V.et al. (1998). The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245-258. 1

Childhood Experiences Underlie Suicide

0

5

10

15

20

25%

Atte

mpt

ing

Suic

ide

ACE Score

12

0

3

4+

Fellittii, V.et al. (1998). The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245-258.

0

2

4

6

8

10

12

0 1 2 3 4 5 6 >=7

NoYes

ACE Score

Ever

Hal

luci

nate

d* (%

)

AbusedAlcohol or Drugs

*Adjusted for age, sex, race, and education. Fellittii, V.et al. (1998). The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245-258.

ACE Score and Hallucinations

Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences

ACEs Source: Dong et al, 2004

Od

ds

Rat

io

0 1 2 3 4 5,6 7,8

0.5

1

1.5

2

2.5

3

3.5
















Neocortex

Limbic

Diencephalon

Brainstem


Affiliation

"Attachment"




Body Temperature

Sleep

Motor Regulation


INTERPERSONAL NEUROBIOLOGY

LENGTH OF SENTENCES (PORGES‐EXTENDED EXHALE)PARALLELING (PERRY)EYE CONTACTFACIAL EXPRESSIONTONE OF VOICEPOSTUREGESTURETIMING OF RESPONSE

DR. DANIEL SIEGEL MD(TRAUMA, BRAIN & RELATIONSHIP: HELP CHILDREN HEAL. HTTPS://WWW.YOUTUBE.COM/WATCH?V=JYYEEMLMMB0)

A Shared Experience

• Physicians feel pain and relief of clients

Jensen KB, et al. Molecular Psychiatry. 2014;19:392‐398.

Qualia vs Intentionality(phenomenal consciousness vsrepresentation of mental states)

…the difference between the patient’s experience of the disease and the doctor’s

attention to the disease…

Arthur Kleinman, MDPsychiatrist Harvard Medical School

Professor, Anthropology Harvard University

Kleinman, A. 1988. The Illness Narratives: Suffering Healing and the Human Condition. NY, NY: Basic Books.

Neurobiology of Helplessness

TRAUMA: Any life event occurring in a relative state of helplessness‐a car accident, the sudden death of a loved one, a frightening medical procedure (…)‐can produce the same neurophysiological changes in the

brain as do combat, rape or abuse.

Robert Scaer M.D.Neurologist, Traumatologist, Medical Director of Internationally recognized Pain

Management Center at Mapleton Rehabilitation center, Community Hospital Boulder, Colorado

LIKE FATHER, LIKE SON?

• BIPOLAR 1 DISORDER W/PSYCHOTIC FEATURES

• ADDICTION

• POSTTRAUMATIC STRESS DISORDER

• COMPLEX TRAUMA

• 2 SUICIDE ATTEMPTS

• 265 POUNDS IN 7TH GRADE

Absolute Shattering of the “Self”•Physiological•Cognitive•Spiritual•Social•Familial

Diagnosis

• Bipolar Disorder 1• Addiction• Developmental Trauma• Posttraumatic-Stress Disorder• 2 suicide attempts-1 near lethal

My soul is lost, my friendTell me how do I begin again?

Bruce Springsteen“My City’s In Ruins”

The Rising

An Integrated Perspective

ACE

BIPOLAR

ALCOHOLISM

DRUGADDICTION

SUICIDE

TRAUMA

CHILDHOODOBESITY

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Trauma‐Informed Recovery

• CLIENT• ORGANIZATIONAL

ACCELERATION OF OUTCOMES

MUTUALLY THERAPEUTICDYADIC ATTUNEMENT (MTDA)

Identity is a relational achievement (Mokros, HARTMUT B., Suicide and Shame , American Behavioral Scientist, 38:8

(1995:Aug.)

RELATIONAL POVERTYBRUCE PERRY MD PHD

INTERPERSONAL ATTUNEMENT: THE WAY ONE PERSONATTUNES IN AN OPEN AND EMPATHETIC WAY TO THEINTERNAL STATE OF ANOTHER.

INTERPERSONAL RESONANCE: THE WAY TWO OR MOREMINDS ALIGN THEIR STATES AND BECOME MUTUALLYINFLUENCED BY ONE ANOTHER.

DAN SIEGEL MD CREATOR INTERPERSONAL NEUROBIOLOGY

INTERPERSONAL NEUROBIOLOGY

LENGTH OF SENTENCES (PORGES‐EXTENDED EXHALE)PARALLELING (PERRY)EYE CONTACTFACIAL EXPRESSIONTONE OF VOICEPOSTUREGESTURETIMING OF RESPONSE

DR. DANIEL SIEGEL MD(TRAUMA, BRAIN & RELATIONSHIP: HELP CHILDREN HEAL. HTTPS://WWW.YOUTUBE.COM/WATCH?V=JYYEEMLMMB0)

Verbal De‐escalation

When working with an agitated patient, there are 4 main objectives:(1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and(4) avoid coercive interventions that escalate agitation.

Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Zeller, S. L., Wilson, M. P., … Ng, A. T. (2012). Verbal De‐escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De‐escalation Workgroup.Western Journal of Emergency Medicine, 13(1), 17–25. doi:10.5811/westjem.2011.9.6864

SafetySafety

ProximityProximity

IntimacyIntimacy

VulnerabilityVulnerability

POINT OFCONNECTION

POLYVAGAL THEORY:THERAPEUTIC DYADJUMPING TOGETHER

• AUTONOMIC NERVOUS SYSTEM

• SOCIAL ENGAGEMENT SYSTEM: NEUROCEPTION

• PRO-SOCIAL, FIGHT OR FLIGHT, FREEZING/IMMINENT DEATH

• INTERVENTIONS: HEART TO FACE, HEART TOVOICE, HEART TO EYES

(PORGES SW. THE POLYVAGAL THEORY: PHYLOGENETIC SUBSTRATES OF ASOCIAL NERVOUS SYSTEM. INTERNATIONAL JOURNAL OF PSYCHOPHYSIOLOGY42 (2001) 123-146.)

Polyvagal Theory

• Physiological state characterized by ↑ vagal influence on HRV supports social engagement & bonding

• Any s mulus that ↑s feeling of safety can recruit neural circuits that support social engagement system and inhibit defensive limbic structures

• Neuroception enables social behavior by distinguishing safe from dangerous

(SW Porges. 2009. The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic J Med 76(3):S86‐S90)

2012 RPBrown & PLGerbarg

POLYVAGAL THEORY:THERAPEUTIC DYAD

SOCIAL ENGAGEMENT SYSTEM

• POSTURE

• BREATHE

• VOICE

(PORGES SW. THE POLYVAGAL THEORY: PHYLOGENETIC SUBSTRATES OFA SOCIAL NERVOUS SYSTEM. INTERNATIONAL JOURNAL OFPSYCHOPHYSIOLOGY 42 (2001) 123-146.)

BROWN RP, GERBARG PL. 2009. HOW TO USE HERBS, NUTRIENTS, AND YOGA INMENTAL HEALTH CARE. NY; WW NORTON. P79.

VAGAL NERVEPATHWAYS

64

EXPERIENTIAL EXERCISES

GREGORIAN CHANTING

YES/NO TEST: REACTIVE VS. RESPONSIVE STATE

(SYMPATHETIC VS. PARASYMPATHETIC ACTIVATION)

BEE BREATH: PRANAYAMA BREATHING

EXTEND EXHALE

POLYVAGAL INTERVENTION

SELF REGULATE ANSPROXIMAL ABANDONMENT: IT IS ALL IN THE

EYES.DR. ALLAN SCHORE

Culture of NO

Yes and NO

• Integrate or Regulate• Reactive or Responsive• Differentiation and Linkages• Chaos or Rigidity

Neocortex

Limbic

Diencephalon

Brainstem


Affiliation

"Attachment"




Body Temperature

Sleep

Motor Regulation


Speaking the Unspeakable

“THE ORDINARY RESPONSE TO ATROCITIES is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud:

this is the meaning of the word unspeakable.Atrocities, however, refuse to be buried.”

― Judith Lewis Herman, Trauma and Recovery

ORAL EXPLORATORY NARRATIVE PROCESSING

Effective treatment is a matter of helping individuals keep the observing prefrontal

cortex online as it simultaneously experiences the raw primitive sensations generated in the

archaic portions of the brain (the limbic system, hypothalamus and brain stem.)

(Levine, P., In An Unspoken Voice. Berkeley: North Atlantic Books,2010, 71.)

STILL FACE EXPERIMENT

HTTPS://WWW.YOUTUBE.COM/WATCH?V=APZXGEBZHT0

VALIDATION THERAPY

• INTERPERSONAL RESONANCE

• INTERPERSONAL ATTUNEMENT

• VERBAL COMMUNICATION: PROSODY, SLOW, VOICE TOHEART

• NON-VERBAL COMMUNICATION

• AMYGDALA SQUELCHING: TOUCH SPECIFIC

• RELATION POVERTY: DR. BRUCE PERRY

• LANGUAGE OF THE OTHER: CORTICAL SHUTDOWN, IMPLICIT MEMORY

HTTPS://WWW.YOUTUBE.COM/WATCH?V=CRZXZ10FCVM
















Breath‐Body‐Mind includes the following breathing practices

• Coherent Breathing– Rate: 3.5 to 6 breaths per minute– Equal inhalation and exhalation– Like natural breathing: quiet and gentle

• Breath Moving: imaginative• Resistance Breathing on exhalation• “Ha” Breath (briefly 2 to 5 minutes)• 4‐4‐6‐2 Counts Breathing(RP Brown & PL Gerbarg (2012). The Healing Power of the Breath.

Book + CD. Boston: Shambhala Press.)

Neocortex

Limbic

Diencephalon

Brainstem


Affiliation

"Attachment"




Body Temperature

Sleep

Motor Regulation

All rights reserved © 2004 Dr. Bruce Perry

MTDA Tool Belt

79

Documents

A Trauma and Systems Change